Aneurysmal Subarachnoid Hemorrhage: A Look into Recent Guidelines

Excerpt

Management of aneurysmal subarachnoid hemorrhage (aSAH) is rapidly evolving, and major guidelines from the two most reputed societies are expected to enormously aid the clinician in making the right decision [1, 2]. The guidelines by the Neurocritical Care Society (NCS) have focused on nine key topics of neurocritical care management [1], whereas the guidelines by the American Heart Association/American Stroke Association (AHA/ASA) also discuss other central facets of aSAH management [2]. Both guidelines are concordant in almost all aspects; however, a subtle difference that might impact the management needs to be discussed. Hyponatremia, natriuresis, and hypovolemia are frequently encountered complications of aSAH, which unfortunately affect the hospital course of these patients. The evidence has been inconsistent regarding its effect on vasospasm and delayed cerebral ischemia (DCI), which makes it difficult to have clear recommendations regarding it. Fludrocortisone or hydrocortisone have been used and have been beneficial in such situations to improve the sodium balance. However, the favorable effect of fludrocortisone on outcome has not been consistent [3, 4]. After a meticulous discussion of the pros and cons, the AHA/ASA has suggested a level 2a recommendation (reasonable to use) for the mineralocorticoids in aSAH [2]. On the contrary, the expert panel in the NCS changed their recommendation from the earlier guideline published in 2011 [5]. They state that “there is insufficient evidence to support mineralocorticoid administration to maintain normal serum sodium concentration and/or even fluid balance or to improve functional outcome”. Lack of clear consensus on this issue can possibly affect the protocolized treatment of the patients. …